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AUTHORIZATION TO RELEASE MEDICAL INFORMATION

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AUTHORIZATION TO RELEASE MEDICAL INFORMATION

... (HIPAA) requires an Authorization to Release Medical Information in order for health care providers to release medical information or records. ... This form should not be used to request records not covered by HIPAA ...

http://www.awppw.org/docs/Generic.HIPAA.authform.doc

Date added: October 13, 2011 - Views: 1069

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Instructions for completing the Standard Authorization Form (SAF)

Members are advised to keep a signed copy for their records. Standard Authorization Form. To Use or Disclose. Protected Health Information (PHI) ... You must check “yes” or “no” if you authorize the release of medical information, test results, ...

http://www.bcbstx.com/pdf/hipaa/hipaa_standard_auth_tx.doc

Date added: October 26, 2012 - Views: 27

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Protocol Template with Guidelines - ACRIN

AUTHORIZATION TO RELEASE/DISCLOSE MEDICAL RECORDS TEMPLATE: ... By signing this authorization form, I am permitting the release of medical records to ACRIN by my treating doctors on past, ... Protocol Template with Guidelines ...

http://www.acrin.org/Portals/0/Protocols/4701%20-%20RESCUE/Authorization-ACRIN%204701-RESCUE_Amend1_050411.doc

Date added: September 24, 2012 - Views: 94

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Instructions for completing the Standard Authorization Form (SAF)

I request and authorize Blue Cross and Blue Shield of Oklahoma to disclose my protected ... You must check “yes” or “no” if you authorize the release of medical ... Members are advised to keep a signed copy for their records. Standard Authorization Form. To Use or Disclose. ...

http://www.bcbsok.com/pdf/hipaa/hipaa_standard_auth_ok.doc

Date added: September 28, 2012 - Views: 3

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HIPAA Authorization Form - UMBC: An Honors University In Maryland

Authorization Form for Release of Records and Information. COMPLETE SECTION A: A. Identification. ... ___ My Medical Plan (Name):_____ ___ My Dental Plan (Name):_____ ___ My Prescription Plan (Name ...

http://www.umbc.edu/hr/MS%20Word/HIPAA%20Authorization%20Form%20Final%20Revised%20April%203%202003.doc

Date added: September 25, 2011 - Views: 126

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HIPAA DISCLOSURE AUTHORIZATION FORM - Michigan

... although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. ... HIPAA DISCLOSURE AUTHORIZATION FORM ...

http://michigan.gov/documents/CS-1786_HIPAA_Disclosure_Authorization_92773_7.doc

Date added: September 25, 2011 - Views: 25

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STANDARD AUTHORIZATION, ATTESTATION AND RELEASE

... including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, ... Attestation and Release. ... STANDARD AUTHORIZATION, ATTESTATION AND RELEASE Author: Bruce Long Last modified by: Bruce

http://www.ajriggins.com/STANDARD_AUTHORIZATION.doc

Date added: February 2, 2012 - Views: 9

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MEDICAL RECORD GUIDELINES - Kentucky

Medical records shall be maintained in accordance with the following guidelines: ... The policies regarding the release of medical records shall be posted ... The Release of Information form shall serve as the official request of patient information and shall be filed in the medical record ...

http://chfs.ky.gov/NR/rdonlyres/281664D4-FBC3-45E1-94A7-98700EFF4E3B/0/ARVolISection10MedicalRecordsManagement.doc

Date added: October 3, 2011 - Views: 125

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Caregiver Consent Form - Arizona State University

Caregiver Consent Form for Emergency Treatment. ... To give the Caregiver Consent Form to the Emergency Medical Service or to take it to the emergency room so all necessary information for prompt and appropriate care will be available in your absence.

http://www.asu.edu/studentaffairs/reslife/family/docs/Caregiver%20Consent%20Form%20for%20Medical%20Treatment.doc

Date added: October 2, 2011 - Views: 802

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HIPAA REQUIREMENTS - Campania

I then listed some facts that may be helpful when reviewing requests for medical records. The HHS website is a good source of information and should be checked periodically for any updates pertaining to the HIPAA. A Medical Record Release needs to ... One authorization form may be used to ...

http://www.thecampaniagroup.com/lossprevention/Tools/HIPAA%20REQUIREMENTS.doc

Date added: January 30, 2012 - Views: 37

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Consent Form Language for HIPAA Compliance

Below is sample language for the consent form and suggestions for where it may be added. ... be included in your medical record. Your records may be reviewed in order to meet federal or state regulations. Reviewers may include [representatives from the Food and Drug Administration, ...

http://irb.duhs.duke.edu/wysiwyg/downloads/HIPAA_Language_04-11-08_for_website.doc

Date added: November 12, 2011 - Views: 38

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1 - Forms in Word (formsinword.com)

FIW-M15A Authorization to Release Medical Records Form Medical Clinic Form in Word. ... FIW-M28 Standard Medical Invoice Medical Clinic Form in Word. FIW-M47 Driver Examination Form Medical Clinic Form in Word.

http://formsinword.com/Word%20Files/List%20of%2046%20medical%20forms%20in%20Forms%20in%20Word%20Medical%20package.doc

Date added: June 8, 2012 - Views: 5

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Medical History and Examination Form

... I authorize the release to my employing agency of all information contained on this examination form and all other forms generated as a direct result of my examination ... Standard Medical History and Examination Form. ... of pertinent medical records.) ...

http://www.doi.gov/safetynet/information/general/medical/Medical%20History%20and%20Evaluation%20Form.doc

Date added: September 16, 2011 - Views: 167

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Authorization - Home | Rowan University

Authorization for Release of Information Form. ... When a patient arrives and requests a copy of their medical records, ... NOTE: The steps detailed in this workflow are based on a standard Laptop.

http://www.rowan.edu/som/ist/clinicalsystems/documents/AuthforReleaseofInfoforMedRecords062513.docx

Date added: November 1, 2013 - Views: 1

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MEDICAL CARE - U.S. Immigration and Customs Enforcement

This Detention Standard replaces Medical Care dated 9/12/2008. ... The In Processing Health Screening form I-795A or medical facility equivalent will be completed during the in-processing and prior to the detainee’s placement in a housing ... Confidentiality and Release of Medical Records.

http://www.ice.gov/doclib/dro/detention-standards/doc/medical_care.doc

Date added: September 24, 2011 - Views: 27

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www.unityhealth.org

... that may be used/disclosed as indicated in the protocol e.g., your research record, related information from your medical records, ... the study investigator may share a copy of this consent form and records that identify you ... standard medical care and any other benefits to which you ...

http://www.unityhealth.org/IRB/Forms/AuthforReleaseofInfo10-09.doc

Date added: March 20, 2014 - Views: 1

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United Healthcare Medical Claim Form - CITGO

pharmacist to release any information requested with regard to this claim and the expenses reported. ... hospital records? ... United Healthcare Medical Claim Form ...

http://www.citgo.com/WebOther/EmployeesRetirees/UHCMedicalClaim.doc

Date added: January 27, 2012 - Views: 44

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Ketchikan Fire Department - Alaska Health and Social Services

... be certified as an Emergency Trauma Technician in the State of Alaska. ... 8.2.6 Requests for copies of run reports must be made on the "MEDICAL RECORDS RELEASE F0RM11. The form will be filed with the run report. ... and accompanied by a release form, signed by the patient or legal guardian.

http://dhss.alaska.gov/dph/Emergency/Documents/ems/assets/Downloads/sog-sops.doc

Date added: May 11, 2013 - Views: 11

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Informed Consent Template - Spectrum Health System | Grand ...

Medical records requires for ... By signing this consent form you will not be waiving any of your legal rights which you otherwise would ... that an oral presentation was interpreted fully and accurately by the Spectrum Health appointed medical interpreter in the participant’s ...

http://www.spectrumhealth.org/documents/research/forms/Informed%20Consent%20Template.doc

Date added: November 19, 2011 - Views: 30

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Eagle’s Wings Retreat Center

Parent/GuardianMedical/Liability Release Form. ... For our records and for any possible emergencies that might arise while at the retreat center, ... diagnosed, treated, and/or given medication in accordance with standard medical practice.

http://www.ewrc.org/Medical-liability%20release%20form-child.doc

Date added: August 27, 2013 - Views: 1

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SAMPLE DISCHARGE LETTER - Campania

Enclosed, please find a copy of a medical. records release authorization form for you to complete and return to. my office as soon as possible. While it is unfortunate that our relationship has reached this. ... SAMPLE DISCHARGE LETTER ...

http://www.thecampaniagroup.com/lossprevention/Tools/SAMPLE%20DISCHARGE%20LETTER.doc

Date added: November 3, 2011 - Views: 530

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Illinois Department of Corrections - IDOC : Home

I have been informed that the rules of the Illinois Department of Corrections and/or the laws of the State of Illinois (720 ILCS 5/31A) ... Physical Agility and Medical Release ... I will be required to participate in a standard physical agility test. I hereby state that I have no known ...

http://www.idoc.state.il.us/subsections/jobopp/doc0035%20rev2004%209%20EmployeeReleaseConsent.doc

Date added: November 10, 2011 - Views: 17

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Medical Examination Form Initial-Hire Medical Standards

... only the relevant section of the applicable Medical Standards should be referenced on the form. Medical examination records are the property of the ... The release provided will permit the examining health care ... Physician must certify whether candidate passed or failed the medical exam:

http://www.mass.gov/anf/docs/hrd/cs/medicalstandardspat/cs-pat-med-exam-form.doc

Date added: February 1, 2012 - Views: 160

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THE QUEEN’S MEDICAL CENTER - Office of Research and ...

Please do not use “I/you understand that” in any place on the consent form. Title of Study: Principal Investigator: Address. Phone. ... The individuals or groups named above may release your medical records, ... The Queen’s Medical Center and the study researchers have not set aside any ...

http://www.rpd.queens.org/downloads/rirc_irb/doc/consentHIPAA-Nov11.DOC

Date added: May 17, 2013 - Views: 2

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DOL FORM 7

... Minimum data to justify services and payment, including that on the standard paper 1500 form or electronic. 837 form. (2) ... Release of relevant medical records by health care providers; department to oversee . release and.

http://aoa.vermont.gov/sites/aoa/files/pdf/wcp/BGS-WC-medical-auth.doc

Date added: September 14, 2013 - Views: 1

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D E T E N T I O N S T A N D A R D - U.S. Immigration and ...

Either the USM 553 Form or a facility-specific ... Confidentiality and Release of Medical Records. in the Detention Standard on ... and notify the receiving facility in writing that the transferring facility requires notice before the detainee’s release or further transfer to ensure ...

http://www.ice.gov/doclib/dro/detention-standards/doc/transfer_of_detainees.doc

Date added: October 30, 2011 - Views: 21

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Physician's Guide Initial-Hire Medical Standards - Mass.Gov

The purpose of the standard Medical Examination Form ... Should have medical records and glucose meter logs reviewed periodically. ... The specific written consent of the candidate shall be required to release confidential medical information to the fire department, ...

http://www.mass.gov/anf/docs/hrd/cs/medicalstandardspat/cs-pat-physicians-guide.doc

Date added: February 12, 2012 - Views: 35

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(Program Title) - School-Based Health Alliance

A ‘Consent to Release Information’ form must be completed by the student or parent before records ... SBHCs will not release student’s medical records pertaining to ... standard for medical records for compliance, and institutes corrective action if indicated. For more ...

http://ww2.nasbhc.org/RoadMap/PracticeCompliance/Policy/Medical%20Records%20Overview%20Sample%20Policy.doc

Date added: May 30, 2013 - Views: 8

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Company Policy: Unauthorized Disclosure of Protected Health ...

... or serious violation of medical records release procedures Company will impose disciplinary action up to and ... Completes the Unauthorized Disclosure of Protected Health Information Investigation Form to the ... one page of the records supporting the unauthorized ...

http://www.ehcca.com/presentations/HIPAA7/2_01H2.doc

Date added: March 4, 2012 - Views: 10

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Instructions for completing the Standard Authorization Form (SAF)

Members are advised to keep a signed copy for their records. Standard Authorization Form. To Use or Disclose. Protected Health Information (PHI) ... You must check “yes” or “no” if you authorize the release of medical information, test results, ...

http://provider.bcbsil.com/PDF/hipaa/hipaa_standard_auth_il.doc

Date added: August 19, 2014 - Views: 1

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Application Form

... 4 to be completed by the medical practitioner. NOTIFYING MEDICAL ... listed in section 4 of this application form. I authorise the release of all personal medical information provided in relation to ... Please submit the COMPLETED form (keeping a copy for your records) to: International ...

http://www.itftennis.com/itf/web/data/antidoping/TUE%20Application%20Form.doc

Date added: May 28, 2013 - Views: 6

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MEDICAL RECORD GUIDELINES - Kentucky

All medical records must be maintained in a standard format with entries and forms filed in chronological order ... 6.The policies regarding the release of medical records shall be ... The Release of Information form shall serve as the official request of patient information and shall ...

http://chfs.ky.gov/NR/rdonlyres/CFFF5FA5-04CC-4E6A-B878-48858FBCE3B1/0/ARVolIMedicalRecordsManagement.docx

Date added: October 7, 2012 - Views: 90

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Topic: HIPAA Terminology - University of California, Berkeley

The study creates new medical records because as part ... addresses and medical record numbers by office staff who mail out requests to community physicians for release of medical records of ... (which may be separate or a component of the research consent form) that these records will not be ...

http://cphs.berkeley.edu/hipaa/HIPAAtutorial.doc

Date added: October 10, 2011 - Views: 19

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NAVAL MEDICAL CENTER - Navy

,” being conducted at the Naval Medical Center Portsmouth, ... This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an ... IF THE CONSENT FORM IS FOR THIRD ...

http://www.med.navy.mil/sites/NMCP2/EduTrain/CID/Documents/RAForms/IRB_Consent_Template.doc

Date added: April 7, 2013 - Views: 7

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Contractor's Release Form - DHCS Home Page

CONTRACTOR'S RELEASE. Instructions to Contractor: With final invoice(s ... All expense and accounting records related to the above referenced contract must be maintained for audit purposes for no less than three years ... contractor release form Last modified by: dlewis1 Created Date: 1/6/2003 ...

http://www.dhcs.ca.gov/services/rural/Documents/ContractorReleaseForm.doc

Date added: November 24, 2011 - Views: 111

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Consent Form Template Standard - Northwest Institute of ...

We may ask you to sign a medical records release to obtain medical records collected from places other than the University of Washington Medical Center. You may refuse to sign this release. OTHER INFORMATION. ... Consent Form Template Standard ...

http://www.nwigm.org/resources/RepositoryMinorPT&ICFCL.doc

Date added: January 30, 2012 - Views: 4

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JACHO REF - Drupal Gardens

STANDARD REFERENCE FORM. ... I release from any liability for their statements, all persons, corporations, ... Maintains current, complete and accurate documentation in medical records. Understands and follows rules of medical confidentiality.

http://southafrica.drupalgardens.com/sites/g/files/g1089046/f/201402/StandardReferenceForm.doc

Date added: April 21, 2014 - Views: 1

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Access to Medical Records - Houston Controls

... area, grab, wipe, or other form of sampling, as well as related collection and analytical methodologies, calculations, ... The name of the individual or organization that is authorized to release the medical information. ... The Access to Employee Exposure and Medical Records Standard ...

http://www.houstoncontrols.com/safety/management_procedures/Access%20to%20Employee%20Medical%20and%20Exposure%20Records.doc

Date added: November 11, 2012 - Views: 9

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Health Information Form for Student Rotators - JPS Health Network

... (Occupational Health Form 1) Major Medical Problems: (Complete Occupational ... If you do not have a pre-signed form in your records, fax a release form to Margie ... Even request from the student requires a completed release form. Standard Authorization to Use or Disclose Protected ...

http://www.jpshealthnet.org/uploadedFiles/For_Medical_Professionals/Academic_Affairs/Educational_Resources/Health-Information-Form-for-Student-Rotators_electronic.doc

Date added: May 7, 2014 - Views: 1

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Access to Employee Medical Records - LARA - MI Department of ...

... to address OSHA access to employee medical records. MIOSHA Standard, Part 470, does not include 1913.10 rules. ... Medical Records Maintained in Electronic Form. ... (Individual/organization holding medical records) _____ to release to the Department of Licensing and Regulatory Affairs, ...

http://www.dleg.state.mi.us/wsh/docs/inst/miosha_com_08_2.doc

Date added: November 9, 2011 - Views: 13

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HIM 2012 Legal Aspects of Health Records - Daytona State College

HIM 2012 Legal Aspects of Health Records. ... of a valid release of information C. Common defects of an invalid release of information D. Minimum necessary standard VIII Release ... Distinguish between specialized patient records and general medical records 8. Describe release of ...

https://webapps.daytonastate.edu/ics/Portlets/ICS/Handoutportlet/viewhandler.ashx?handout_id=1d2c5f18-3744-4786-994b-d6e399ff88ae

Date added: November 5, 2013 - Views: 1

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TEMPLATE Consent Form, Standard - University of Washington

Title: TEMPLATE Consent Form, Standard Author: Helen McGough Keywords: consent, template, sample Last modified by: sherrye Created Date: 5/25/2012 3:53:00 PM

http://www.washington.edu/research/hsd/docs/555?dl=true

Date added: April 28, 2012 - Views: 13

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CJSTC # 58 - FDLE - Florida Department of Law Enforcement

... educational institution, physician, hospital or other repository of medical records, credit bureau or consumer reporting ... F.S. Form Effective Date: 3/2013. Florida Department of. Law Enforcement. CJSTC. 58. Title: CJSTC # 58 Subject: Authority for Release of Information Author: M.B.Henry ...

http://www.fdle.state.fl.us/Content/getdoc/f33876e0-81ad-4a38-b946-7927c3d75510/CJSTC-058-6-9-08-Auto-doc.aspx

Date added: November 2, 2011 - Views: 18

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AUTHORIZATION FOR RELEASE OF INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION ... records, or documents which ... I further authorize _____ hospital to release information in accordance with _____ hospital’s standard policies pertaining to sharing and / or release of confidential information. SIGNATURE.

http://c.ymcdn.com/sites/www.aspr.org/resource/resmgr/imported/Form-Authorization%20for%20Release%20of%20Information-2.doc

Date added: May 12, 2014 - Views: 1

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COVER LETTER/CONSENT FORM GUIDELINES - Wright State University

STANDARD CONSENT FORM FORMAT FOR BIOMEDICAL STUDY ... My medical records and study file may be reviewed at the study site by the sponsor and/or its representatives, ... COVER LETTER/CONSENT FORM GUIDELINES Author: William Sellers Last modified by: Wm Sellers

http://www.wright.edu/rsp/IRB/Consent_Guide.doc

Date added: October 25, 2011 - Views: 148

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Consent Form: Institutional Review Board (IRB) - UT ...

... state UT Southwestern Medical Center] Please insert the names of the investigators and those individuals who will obtain ... the standard medical care for your ... You should know that certain organizations that may look at and/or copy your medical records for research, quality ...

http://www.utsouthwestern.edu/edumedia/edufiles/research/IRB_Forms/consent-form.doc

Date added: May 2, 2013 - Views: 9

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New Jersey Department of Banking and Insurance

... (IHCAP) operated by the New Jersey Department of Banking and Insurance (DOBI). Through ... of a Utilization Management Determination and Authorization of Release of Medical Records for Appeal and ... BY THE INDEPENDENT HEALTH CARE APPEALS PROGRAM" FORM FOR YOUR RECORDS.

http://www.state.nj.us/dobi/chap352/352ihcapform.doc

Date added: September 21, 2011 - Views: 8

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Indiana FCCLA Multiple Release Form

Colorado ACE Student Leadership Conference Multiple Release Form. ... Retain a copy for your records. MEDICAL RELEASE/AGREEMENT TO ACCEPT FINANCIAL RESPONSIBILITY. The undersigned, ... PUBLICITY - STANDARD RELEASE FORM: ...

http://www.coloradostateplan.com/ACE/12ACE_Multiple_Release_Form.docx

Date added: November 29, 2013 - Views: 1

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TDCJ - Correctional Managed Health Care

Offender electronic medical records may be sorted according to: ... the “filed incomplete” form (Attachment D) ... Management of Health Records (important) ACA Standard 4-4366 (Ref 3-4346) Health Appraisal (Non-Mandatory)

http://www.cmhcc.state.tx.us/CMHC_Policy_Manual/H/H-60.1%20(0909).doc

Date added: October 16, 2011 - Views: 6

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PRIVACY ACT STATEMENT - HEALTH CARE RECORDS

this form provides you the advice required by the privacy act of 1974. this form is not a consent form to release or use heath care information pertaining to you.

http://www.affinityhealthservices.net/clients/standard_manuals/Administrative%20Resource%20Library/PRIVACY%20ACT%20STATEMENT.doc

Date added: March 1, 2012 - Views: 11